A nurse is evaluating the use of a nipple shield by a client who is breastfeeding. Which of the following actions by the client demonstrates correct use of the nipple shield?

The client places the nipple shield under the nipple to collect wasted milk.

The client expresses breast milk into the nipple shield for storage.

The client places the nipple shield over the nipple prior to feeding.

The client uses the nipple shield to relieve breast engorgement.

Answer and Explanation

The Correct Answer is C

A. The client places the nipple shield under the nipple to collect wasted milk: The nipple shield is not designed to collect milk. Its primary purpose is to help the infant latch onto the breast more effectively, especially if the mother has difficulty with breastfeeding or if the infant has trouble latching. Placing the nipple shield under the nipple to collect milk would be an incorrect use of the device.
B. The client expresses breast milk into the nipple shield for storage: While expressing breast milk is a common practice, the nipple shield is not intended to be used for milk storage. Its role is to provide a barrier and support to facilitate feeding.
C. The client places the nipple shield over the nipple prior to feeding: This is the correct use of the nipple shield. It is designed to be placed over the nipple before feeding to help the infant latch effectively, especially for mothers with inverted or flat nipples, or when the infant has difficulty latching properly. The nipple shield supports a more effective breastfeeding experience.
D. The client uses the nipple shield to relieve breast engorgement: The nipple shield is not designed to relieve breast engorgement. While it can assist with latching, engorgement typically requires other interventions such as warm compresses, frequent breastfeeding, or expressing milk to alleviate the discomfort and restore normal breast tissue function.

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Correct Answer is A

Explanation

A. Elevate the head of the bed: Raising the head of the bed to at least 30 to 45 degrees is the first and most essential action to reduce the risk of aspiration during enteral feeding. This position helps ensure that the formula flows into the stomach by gravity and minimizes the potential for reflux of gastric contents into the lungs, which can lead to aspiration pneumonia.
B. Attach the barrel of the syringe to the tube after removing the plunger: This step is necessary for gravity-based enteral feeding when using a syringe. However, it should only be done after confirming tube placement and ensuring the patient is positioned properly. Attaching the syringe before proper safety precautions increases the risk of aspiration.
C. Insert air into the tube before pulling back gastric contents: Injecting air into the gastrostomy tube is part of the verification process to confirm tube placement, often followed by aspirating gastric contents. While this is important, it is not the very first action. The client's head must be elevated first to ensure safety before any manipulation of the tube begins.
D. Flush the tube with 30 mL water: Flushing is necessary to ensure tube patency and to prevent blockage before and after feedings. However, it is not the first step in the procedure. Elevating the head of the bed comes before flushing to prevent aspiration during any subsequent feeding or fluid administration.

A. Place the head of the client's bed to 30° for meals. B. Encourage the client to chew on both sides of their mouth. C. Describe food locations as if the client's plate were a clock. D. Provide the client with wide-grip adaptive utensils.

Correct Answer is C

Explanation

A. Place the head of the client's bed to 30° for meals: Elevating the head of the bed to 30° is not sufficient to prevent aspiration in a client who has difficulty eating after a stroke. A 90° angle or as high as tolerated is typically recommended during meals to reduce the risk of aspiration and ensure safe swallowing. A lower elevation increases the chance of food or liquid entering the airway.
B. Encourage the client to chew on both sides of their mouth: Clients who have had a stroke often experience unilateral weakness, including facial and oral muscle weakness. Encouraging them to chew on both sides may not be feasible and can increase the risk of choking if one side of the mouth is significantly paralyzed. Instead, focusing on the stronger side for chewing is safer.
C. Describe food locations as if the client's plate were a clock: This technique is especially helpful for clients with visual field deficits, such as hemianopia, which is common after a stroke. Describing food using the clock method helps orient the client to the location of items on the plate, promoting independence and reducing frustration during meals.
D. Provide the client with wide-grip adaptive utensils: Wide-grip adaptive utensils are beneficial for clients with impaired fine motor skills or limited hand strength, which may occur after a stroke. However, while helpful, this intervention does not directly address the primary issue of difficulty eating due to perceptual or cognitive deficits.

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